St.

Joseph’s College Department of Nursing

NU 205 Nursing Care of Childbearing Families
Maternal Plan of Care
Guerlene Jerome Date of Care _3/20/2023_____ Pt. Initials_MT___ Age 26____ Room #_515____EDD_____
Date/Time Delivery 9/19/2023, 21:19 Gestation: 37
Pre-Delivery: G:__2___ P:1_____ (T:_1___P__0___A_0__L__1___); Post-Delivery:
G:___2_P:__2__(T:1____P:__0___A:__0__L:__2___)
Pregnancy History: Uncomplicated pregnancy
Type of Delivery: vaginal Reason: Spontaneous vaginal delivery EBL: 300 ml
Wt: 70.2 kg Diet: Regular Appetite: Appetite is present: Formula/Breast/Frequency: Breast Feeding
Admitting Diagnosis: Labor spontaneous vaginal delivery
LMP: N/A Allergies: None
Surgical Procedurre /S, Episiotomy, Laceration, Anesthesia,): None
PMH/PSH/Social/Family: (include childhood medical hx): None, never smoked, anemia.

Labor Hx: 15 hours of labor, no pain management per patient’s request

Planned/Unplanned Pregnancy: Planned Pre/Post Delivery weight:__70.2 kg Weight gain: 21 lbs
Immunization Profile : Covid vaccine Activity: N/A
Vital Signs: T: 36.8 Pulse: 90 Apical: 68 RR: 18 B/P: 123/83_ SaO2 100 Pain Scale: 6
IV: Lactated Ringer 1000mL rate of 125mL/hr left hand vein, 18 gauge ( Solution, Site, Gauge, Date, Time)
Intake: 500 ml Output: 300 ml Foley Catheter: N/A Drains: N/A

Laboratory Evaluation
Test Date Result Normal/Abnormal/Significance
H&H
Platelets 3/16/2023 157 Normal
WBC 3/16/2023 8.22 Normal
Blood group and 3/16/2023 B+ Normal
type
Antibody screen 3/16/2023 negative Normal
Rubella titer N/A N/A N/A
Hepatitis B 3/16/2023 negative Normal
Sickle Cell N/A N/A N/A
Pap smear N/A N/A N/A
Gonorrhea 3/16/23 Negative
Chlamydia 3/16/2023 Negative
Group Beta strep 3/16/2023 Negative
Herpes 3/16/2023 Negative
Urinalysis 3/16/2023 Normal
Lead Screening N/A N/A N/A
Blood Glucose 3/16/2023 82 Normal
screening
Other Lab Results N/A N/A N/A

Medications taken in pregnancy (prescriptions, herbal supplements over the counter)

Tylenol Dose 650mg Frequency Q6 Route Oral Indication pain

Lactate ringer Continous IV Hydration/electrolytes

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St. Joseph’s College Department of Nursing
NU 205 Nursing Care of Childbearing Families
Maternal Plan of Care

Medications in labor and Postpartum

Name Dose Frequency Route Indication

Postpartum Assessment

B Breast is palpated soft, fuller, and nontender. There is presence of colostrum from the nipple.

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St. Joseph’s College Department of Nursing
NU 205 Nursing Care of Childbearing Families
Maternal Plan of Care
U Uterine is firm located in the midline and one finger breath above the umbilicus.

B Bladder is not distended. Patient voided 300 ml of urine

B Bowel sounds present in all four quadrants. Patient is yet to pass stool post delivery

L Lochia is rubra color and moderate in amount. Contains small shedding of clots

E/I (episiotomy laceration, incision) Perineum intact

E Patient is bonding with baby.

E Lower extremities normal.

E No epidural

List 3 Learning Needs for this Patient

1. Pain management.

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St. Joseph’s College Department of Nursing
NU 205 Nursing Care of Childbearing Families
Maternal Plan of Care
2. Proper breast-feeding techniques.

3. Perineum care.

List 3 Nursing Problems in Priority Order

1. Acute pain related to vaginal birth as evidenced by patient verbalizing “I have intense pain in my perineal
area”.
2. Deficient knowledge related to breastfeeding.

3. Risk for infection related to spontaneous rupture of membrane and repeated vaginal examination, during
labor.

Plan of Care

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 St. Joseph’s College Department of Nursing
NU 205 Nursing Care of Childbearing Families
Maternal Plan of Care
1.Nursing Problem
Acute pain related to vaginal birth as evidenced by patient verbalizing “I have intense pain in my perineal area 8 out of
10” on a scale of 0-10.

Expected Outcomes
1. 1. Patient will report a decrease in pain level within 1 hour and pain level will decrease.
2.

Interventions
1. 1. Assess patient nature of pain using the five keys component of pain assessment regularly every 1 hour.
Rationale: Regular assessment on patient will determine effectiveness of pain management. (Elsevier Mosby, 2020)

2. 2. Educate client on the use of cold compress on the perineal area the first 24 hours and the use of sitz bath after 24
hours.
Rationale: Cold compresses helps reduce swelling and relieve pain after vaginal childbirth. Sitz bath increase blood
flow to the perineal area and promote comfort. (Mayo clinic, 2022)

3. 3. Administer pain medication as needed per order.

Rationale: use of relaxation techniques help distract patient from the presence of pain. (Mayo clinic, 2022)

Evaluations
After one hour patient reported decrease in pain from 8 to 4, on a scale of 0 to 10.

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 St. Joseph’s College Department of Nursing
NU 205 Nursing Care of Childbearing Families
Maternal Plan of Care

1. Nursing Problem Risk for infection related to rupture of membrane and repeated vaginal examination
during labor.

Expected Outcomes
1.
2.1. Patient will be free from any sign and symptoms of infection such as elevated temperature, swelling in the perineal area
and tachycardia etc.

Interventions
1. 1. Educate patient on the signs and symptoms of infection and to report as soon as possible fever, foul odor from
perineum area, and pain with urination.
Rationale: Early detection and report of sign of infection will prevent the progression of infection into
sepsis. (Elsevier Mosby, 2020)
2. 2. Teach patient on proper hand washing technique.
Rationale: The use of aseptic technique such as frequent handwashing reduces infections.
(Elsevier Mosby, 2020)
3. 3. Demonstrate the proper way of performing perineal care by wiping from front to back.
Rationale: Peri pads should be removed from front to back to prevent introducing bacterial from the rectum to the
vagina. (Mayo clinic, 2022)

4. Monitor temperature and pulse every four hours.

Rationale: Vital signs serve as crucial indicators of infection. (Elsevier Mosby, 2020)

Evaluations

Patient vital signs remind normal during my shift.

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 St. Joseph’s College Department of Nursing
NU 205 Nursing Care of Childbearing Families
Maternal Plan of Care

2. Nursing Problem Deficient knowledge related to breast feeding.

Expected Outcomes

1. 1. Patient will be able to understand the proper technique of breast feeding.

2.

Interventions
1. 1. Teach proper latching techniques for breast feeding.
Rationale: Proper latching techniques will prevent nipple soreness. (Elsevier Mosby, 2019)
2. 2. Teach multiple teaching tools, such as written, videos and demonstration when teaching patient.
Rationale: different learning techniques helps patient to fully retain and understand information presented to them
and can demonstrate it back during teach back time. (Elsevier Mosby, 2019)
3. 3. Encourage patient to ask questions.
Rationale: Asking questions concerning care indicate patient is actively participating in the formation and
demonstrate a desire to learn more. (Elsevier Mosby, 2019)

Evaluations
Patient shows initiative in care and demonstrates and verbalizes understandings.

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St. Joseph’s College Department of Nursing
NU 205 Nursing Care of Childbearing Families
Maternal Plan of Care

Nurses Note

Patient is a 26-year-old female who delivered at 37 weeks of viable female infant. She is alert, oriented to time, place, and
person. No signs of respiratory distress noted. Uninterrupted skin to skin with positive bonding noted between mother and baby.
Breastfeeding initiated with teaching however, patient needs proper latching techniques to be effective. Vital signs: T- 36.8, P-
90, BP- 123/83, RR- 18, O2 Sat- 100%, Pain- 6 on a numerical pain scale of 0-10. Lochia is rubra and moderate with presence of
small clots with peri pad in place. Mother and baby are rooming in and recuperating well.

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